The Sports Medicine Core Curriculum Lecture SeriesSponsored by an ACEP Section GrantAuthor(s): Kraigher O’Keefe MD and

Jolie C. Holschen, MD FACEP Editor: Jolie C. Holschen, MD FACEP

Head and Neck Injuries in Athletes

Lecture GoalsDiscuss head injuries, c-spine injuries, neck injuries occurring in contact sports

Review acute managementConcussion and cervical spine injuries

Discuss Treatment options Including experimental

Demonstrate proper removal of football helmet and pads.

Sports Associated with Catastrophic InjuriesFootballIce HockeySoccerBasketballRugbyGymnasticsPole VaultingDiving

Case19 y.o. male, playing soccerHit right fronto-parietal head on another’s skullUnconscious for 20 secBrought to ED with amnesia for event, but normal neuro examRight frontal scalp contusionDeveloped seizure, responded to AtivanAdmitted for observationSlight psychomotor slowing with slurred speechPossibly related to Ativan and seizure?8 hours later developed N/V, and headache Repeat CT showed development of interval epidural bleed

Bruzzone, AJSM 2000

Head InjuriesSevere: GCS <8

25% require NS intervention

Moderate: GCS 9-13“talk and deteriorate” 75% SDH or EDH.

• Worse prognosis than when presenting initially with GCS<8

Minor: GCS 14-15Sports related account for 5-10% seen in ED.3% deteriorate unexpectedly<1% require neurosurgical intervention

Rosen’s 6th Ed.

Types of head injuries

Subdural hematomaEpidural hematomaSubarachnoid hemorrhageIntracranial hemorrhageCerebral contusionDiffuse axonal injuryConcussion

PathophysiologyDirect Impact

Skull fractureEnergy transmitted via shock waves

• Distort/disrupt contents, altering ICP

Indirect InjuryAcceleration/deceleration injury

• Bridging subdural vessels strained � SDHDiffuse Axonal InjuryConcussionContrecoup contusion

Rosen’s 6th Ed.

Pathophysiology

Primary brain injury: mechanical irreversible damageBrain lacerationContusion (microvascular injury)Tissue avulsion

Secondary brain injuryDepolarization of brain cells and ionic shiftsFree radical scavengers overwhelmed

Secondary Systemic InsultsHypotension (SBP<90), anemia, hypoxia

Pediatric Considerations

Fewer traumatic hemorrhagic lesionsFewer contusionsMore diffuse brain swellingMore axonal injuryDeterioration more likely 2°/2 edema

ConcussionConcussus- (Latin) “to shake violently”

300,000 US athletes with concussion yearly reported

3-8% high school football players have concussions annually (~150,000/yr)

Up to 19% contact sports players have one concussion per year

Pathophysiology

Alterations in glutamate, potassium and calcium transport

Relative decrease in cerebral blood flow in the setting of an increased requirement for glucose

Symptoms of Concussion ConfusionAmnesiaLoss of consciousnessDisorientationFeeling in a ‘fog’Vacant stare Inability to focusDelayed verbal and motorSlurred speechDrowsiness

HeadacheFatigueDizzinessNausea/VomitingPhotophobiaPhonophobiaEmotional labilityIrritability

Most athletes are symptom free within 15min.Why not return to activity?

Decreased mental ability- judgment, memory

Decreased physical ability- balance, coordination

Re-injury rate high within 10 days of initial injury: 4-6X

Second impact syndrome

Long-term cognitive difficultiesRelationship to depression in retired NFL players?

Second Impact SyndromeSecond, often minor head trauma, occurred before symptoms from first injury have resolved.

Loss of autoregulation of brain blood supply �vascular engorgement � herniation and death.

Controversial (difficult to prove: only case studies)

Cantu, 2006

College Football Data Concussion Risk by Position

Dick, et al. Descriptive Epidemiology of College Football Injuries 1989-1998. JATA 2007;42(2):221-233

Copyright JAT.

College Hockey Data Game Concussion Mechanism

Agel, et al. Descriptive Epidemiology of College Hockey Injuries. J Athl Train. 2007 Apr–Jun; 42(2): 241–248.

Copyright JAT.

Concussion Grading

Cantu Grading SystemRoberts Grading SystemTorg Grading SystemAmerican Academy of Neurology 1997

All segregate severity by loss of consciousness which does not clinically correlate with severity of symptomsAll recommend return to play guidelines based upon duration of symptoms or loss of consciousness

ntu Grading Systeoberts Grading Systeorg Grading Systemmerican Academy o

Cantu. 2001

To CT or not CTGoal to Find:

1. clinically relevant head injuries 2. injuries requiring neurosurgery intervention

New Orleans Criteria:

1. Headache

2. Vomiting

3. Older than 60yrs

4. Drugs or EtOH

5. Persistent anterograde amnesia

6. Visible trauma above clavicle

7. Seizure

Canadian CT Head Rules:

1. GCS <15 2hr after event

2. Suspected open/depressed skull Fx

3. Sign of basilar skull Fx

4. 2 or more episodes of vomiting

5. >65 yr old

6. Amnesia of >30 min prior to event

7. Dangerous mechanism.

CT rough guidelines

All with GCS <15Anterograde amnesiaLOCPersistent vomitingSeizureTrauma above claviclesAge >65

*Role for reliable observation instead of imaging

Neurocognitive ScoringBaseline score at start of season

Head injury Occurs

Re-score when symptom free

Goal is to assist with return to play decision

ImPACT scoring sheet

High school athletes

Baseline testing (20min computerized test: cognitive and motor skills/reaction time)

Re-test after injury on day 2, 7, 14.

McClincy MP et al. Brain Injury, Jan 2006;20(1): 33-39.

ImPACT ConclusionsConcussion grade not related to recovery timeSome ‘Grade 1’ concussions took as long as 14 days to recoverGrading scale not consistent with neurocognitive scoresAmnesia better predictor for outcomes than loss of consciousness

Recovery may not be linear

Neurocognitive defects took longer to recover than self reported symptoms (speed, visual and verbal memory).

McClincy, et al. 2006; Collins et al. CJSM. Jul 2003.

Consensus Conferences on ConcussionVienna Conference 2001

Symptomatic athletes should be withheld from returning to playNo athlete should be returned to play until medically evaluated

Aubry M, Cantu RC, Dvorak J, et al: Summary and agreement statement of the 1st InternationalConference on Concussion in Sport, Vienna 2001. British J Sports Med36(1): 6–10, 2002

Prague Consensus Guidelines 2004Classify as Simple (resolves <10d) vs. Complex (persistent symptoms, seizure, easy recurrence)New SCAT card

Paul McCrory et al: Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med 15( 2):48-55, 2005

Zurich Consensus Guidelines 2008Review of evidence based medicineGradual step-wise return to play outlined

McCrory, P et al. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. CJSM 19(3): 185-200, 2009

Return to Play guidelinesWithhold from play immediately

Step-wise progression of activities1) Complete rest. 2) Light aerobic exercise3) Sports specific exercises with resistance training4) Non-contact training drills5) Full contact training/practice6) Game play

Caution on side of withholding (especially given high likelihood of underreporting of symptoms)Utilization of scoring tests (need accurate baseline score)

Concussion discharge instructionsWhere to get � cdc.gov

Neck injuriesFractures (stable vs unstable):

Compressive-flexion (teardrop)Vertical compression (burst)

Subluxation/DislocationVascular injuryIntervertebral disk herniationBrachial plexus injuryNerve root injury

Spinal Cord Injury:Transverse myelopathyCentral cord syndromeAnterior spinal cord syndromeBrown-Sequard syndromePosterior spinal cord syndromeTransient quadriparesis

Spinal Cord LesionsComplete

Mimicked by spinal shock (<24hr)Check for sacral sparing (central cord)

IncompleteCentral cord

• UE >LE• Older (OA) with hyperextension

Brown-Sequard• Penetrating most common• Ipsilateral motor, contralateral sensory

Anterior Cord• Hyperflexion• Cord contusion � bony fragments or disk• Preservation of position, touch, proprioception

Figure 9, p1085. Algorithm for work up of neck injury. Rahul Banerjee, Mark A. Palumbo and Paul D. FadaleCatastrophic Cervical Spine Injuries in the Collision Sport Athlete, Part 1. Am J Sports Med 2004 32: 1077

CaseHPI:17 y.o. high school football linebackerIntermittent stinging/”lightening” pain down right arm with some tacklesStarted last season, but is more frequent now

PE:Healthy appearingRUE: No muscle wasting, and normal sensation to light touch, temperature, and pain, transiently weaker strength in proximal arm

“Stingers”Key points:

UnilateralSymptoms are temporaryFull recovery of normal functionNo neck pain noted

C5-6 dermatome most often involved- traction or compressionof brachial plexus or cervical nerve root*Up to 50% football players have an episode

Treatment of Stingers

Conservative treatmentSling, Rest, Ice

Return to play:Full cervical range of motionNormal strengthNo symptoms

Case: 18 yo F college gymnast falls onto head coming off of vault c/o neck pain- backboard and c-collar on site

‘Injuries to the Cervical Spine in American Football Players’

1965 – 197440 fatalities

1975 – 198414 fatalities

1985 – 19945 fatalities

*primarily due to tackling

Figure 4. Torg et al. Injuries to the Cervical Spine in American Football Players. JBJS 84-A (1):112-122, 2002

www.jbjs.org

Mechanics of injury

Axial loading with cervical flexion (30º)Excessive forces -> segmental buckling, fractures or dislocation

Figure 3. Torg et al. The epidemiologic, pathologic, biomechanical, and cinematographic analysis of football induced cervical spine trauma. AJSM 18 (1):50-57, 1990

When to Image Neck Injuries?

Canadian C-Spine Guidelines

Midline tenderness

Age >65

Dangerous mechanism

Neurologic symptoms

Supine position

Immediate onset of neck pain

Able to rotate neck

Stiel, NEJM 2003

NEXUS Low-risk Criteria

No posterior midline cervical tenderness

No intoxication

Normal mental status

No focal neurologic deficits

No painful distracting injuries

Does Hypothermia Work?

Moderate Hypothermia

Hyperthermia following trauma or ischemia aggravates brain injury

Neuroprotective effects of cooling demonstrated

Theoretically, moderate hypothermia reduces inflammation that can cause secondary injury

Moderate Hypothermia

Cooling to 33 degrees Celsius (92 F)

Maintain for 48 hours

Gradually rewarm (1 degree/8 hours)

Moderate Hypothermia

ExperimentalUnknown who (if anyone) benefitsUnknown who may be harmedNOT recommended as routine treatment

Everett = case of 1Vertebrae 3, 4 fracture/dislocationOn-field careHypothermia, steroidsTop-notch surgical treatment

Special Teams Plays

1 head down contact per 1.8 kick returnsEducation on proper tackling techniqueAll head down contact at risk for cervical spine injury

Heck et al.:Risk of head down in high school football: all plays = 25%, kick returns 38%See NATA video “Heads Up: Reducing the Risk of Head and Neck Injuries in Football video”

http://www.nata.org/consumer/headsup.htm

Heck et al 2004

Treatment optionsNeurosurgical involvement

Halo: spinal tractionFacet relocation/spinal fusion

High dose steroids?:Methylprednisone 30mg/kg over 15min,

then 5.4mg/kg/hr over next 23hr if treated within 3hr. (If started at 3-8hr, continue for total of 48hrs)

Do not start if not within first 8hrNFL guidelines: “use the institution’s standard”

Total body cooling (experimental)

SteroidsHigh dose methylprednisone for 24hr

Significant risk of detrimental outcome, especially if extend treatment

“evidence of harmful side effects is more consistent than any suggestion of clinical benefit.”

Miller 2008

Transient quadraplegia• Sensation: burning pain, numbness, tingling,

• Motor: weakness to complete paralysis.

• Transient and complete recovery usually 10-15min, although gradual resolution occurs over 36-48 hr rarely.

• Except for burning paresthesia, no neck pain

• Complete return of motor function and full, pain-free motion of the cervical spine.

Pincer effect

Adults: spinal stenosis

Children: spinal column mobility

Torg 1986

Spinal Stenosis

Injuries related to congenital stenosisDiameter: 18.4 mm

Spinal Stenosis: <14mmCongenital or Acquired

• Degenerative osteophyte formation: repetitive traumaTorg ratio: (vertebral canal/body) <0.8 is not a reliable measure

*Functional Reserve: CSF around cord better predictor

Bailes JAT 2007

Facemask removalRemove facemask in the field:

gain access to airway for transport

Leave helmet on, otherwise

pads elevate body causing extension of neck

NCAA recommends Xray/CT w/ Helmet On

MRI: too much artifact with metal from straps

Swartz 2004

Swartz, E. AJSM. Vol 33, no 8, Waninger K. JATA. 2004;39(3):217-222.

Facemask RemovalNew Riddell Revolution Helmet

Concussion: 5.4 % of Revolution wearers vs 7.6 % other

FM Extractor

Trainer’s Angel

Cordless Screwdriverless movement (any one plane, 2.8°–13.3°)was faster (mean 42.1–68.8 seconds)*Rust/damaged screw head 6%-8% failure

Neurosurgery. 58(2):275-286, 2006.AJSM 33:1210-19, 2005.J Athl Train. 2005 Jul–Sep; 40(3): 169–173.

Helmet RemovalOnly remove helmet/pads if absolutely necessary on field

Need to gain airway accessBroken equipment

Always remove both pads and helmet as a unit

Use team of experienced caregivers (data on cervical spine movement)

Pad/Helmet removalCut Jersey in front and at sleevesCut straps on shoulder pads (front and sleeves)One person maintains cervical alignmentCut chin strap (do not unsnap)Remove ear pads & release air from helmetPlace responders hands directly on skin in thoracic region, with additional people added down the body.Head person removes helmet, rotating anteriorly, then shoulder pads by spreading apart front panels and pulling over the head.Lower the patient, place c-collar.

ImagingInitial lateral cervical spine film for athlete with a suspected neck injury: helmet and shoulder pads on or off? Clin J Sports Med 2002 Mar;12(2):123-6

The answer is on! Clin J Sport Med 2003 Jan;13(1):57-8

Management of the helmeted athlete with suspected spine injury. Am J Sports Med 2004 Jul-Aug;32(5):1331-50

Computed tomography is diagnostic in the cervical imaging of helmeted football players with shoulder pads. J Athl Train 2004 Sep;39(3):217-222

Preventative Measures

Helmets?Increase mass.Concussion data

Mouth guardsRule ChangesTechnique changes (head up tackling)

Take Home Points

Do not return an athlete to competition the same day after sustaining even a mild transient concussion

Keep the helmet and shoulder pads on for transport and initial imaging of head and neck injuries

Be aware that symptoms of bilateral stingers require workupHypothermia for spinal cord injuries is still experimental

NATA ReferencesHeads Up: Reducing the Risk of Head and Neck Injuries in Football videohttp://www.nata.org/consumer/headsup.htmPrehospital Care of the Spine-Injured Athletehttp://www.nata.org/statements/consensus/NATAPreHospital.pdf

Additional ResourcesSport Concussion Assessment Tool

http://www.newamssm.org/SCAT_v13_-_Side_1.dochttp://www.newamssm.org/SCAT_v13_-_Side_2.doc

CDC Resourceshttp://www.cdc.gov/ncipc/tbi/TBI.htmHeads Up: Concussion in High School Sports (for coaches)http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htmHeads Up: Brain Injury in Your Practice (for physicians)http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htmHeads Up: Concussion in Youth Sports (for parents and coaches)http://www.cdc.gov/ConcussionInYouthSports/default.htm

ReferencesAgel, Et al. Descriptive Epidemiology of College Hockey Injuries. J Athl Train. 2007 Apr–Jun; 42(2): 241–248.

Bailes J, Petschauer M, Guskiewicz K, Marano G. Management of Cervical Spine Injuries in Athletes. J of Athletic Training. 2007;42(1):126-134.

Banerjee R, Palumbo MA, Fadale PD. Catastrophic cervical spine injuries in the collision sport athlete, part 1: epidemiology, functional anatomy, and diagnosis. Am J Sports Med. 2004 Jun;32(4):1077-87.

Banerjee R, Palumbo MA, Fadale PD. Catastrophic cervical spine injuries in the collision sport athlete, part 2: epidemiology, functional anatomy, and diagnosis. 2004 Oct-Nov;32(7):1760-4

Bruzzone E, Cocito L, Pisani R. Intracranial delayed epidural hematoma in a soccer player. A case report. Am J Sports Med. 2000 Nov-Dec;28(6):901-3

Cantu, RC. Head injuries in Sports. Br J Sports Med. 1996 Dec;30(4):289-96.

Cappuccino A. Moderate hypothermia as treatment for spinal cord injury. Orthopedics. 2008 Mar;31(3):243-6.

Dick, et al. Descriptive Epidemiology of College Football Injuries 1989-1998. JATA 2007;42(2):221-233

Heck, Clarke, Peterson, Torg, Weis. NATA Position Statement: head Down Contact in Football. J of Athletic Training. 2004;39(1):101-111

McClincy MP, Lovell MR, Pardini J, Collins MW, Spore MK. Recovery from sports concussion in high school and collegiate athletes. Brain Injury, Jan 2006(1): 33-39.

ReferencesMcCrea M, Guskiewicz, et al. Acute Effects of Recovery Time Following Concussion in Collegiate Football Players. JAMA 2003, Vol 290 (19);2556-2563.

Paul McCrory et al: Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004.Clin J Sport Med 15( 2):48-55, 2005. http://www.newamssm.org/Prague.pdf

Miller, SM. Methylprednisolone in acute spinal cord injury: a tarnished standard. J Neurosurg Anesthesiol. 2008 Apr;20(2):140-2.

Morochovic R, Chudá M, Talánová J, Cibur P, Kitka M, Vanický I. Local transcutaneous cooling of the spinal cord in the rat: effects on long-term outcomes after compression spinal cord injury. Int J Neurosci. 2008 Apr;118(4):555-68.

Palluska SA, Lansford CD. Laryngeal trauma in Sport. Curr Sports Med Rep. 2008 Feb;7(1):16-21.

Prehospital care of the Spine-Injured Athlete. Inter-Association Task Force. Dallas, Tx. March 2001. NATA.

Rosen’s Emergency Medicine, 6th ed. Marx, Hockberger, Walls. 2006. Philadelphia, PA.

Stiell IG, McKnight RD, Schull MJ. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. NEJM. Dec 2003;349(26):2510-2518.

Stiell IG, Clement, et al. Comparison of Canadian CT Head Rule and New Orleans Criteria in Patients with Minor Head Injury. JAMA Sep 2005; Vol294(12):1513-1518.

Torge, Guille, Jaffe. Injuries to the cervical spine in American football players. J Bone Joint Surg Am. 2002 Jan;84-A(1):112-22